EXPERIENCE OF LAPAROSCOPIC Rafique Memon

MEDICAL
CHANNEL
Vol. 16, No. 2
GENERAL SURGERY APRIL - JUNE 2010
ORIGINAL PAPER
EXPERIENCE OF LAPAROSCOPIC
CHOLECYSTECTOMY AT SUKKUR
1. M. RAFIQUE MEMON ABSTRACT:
MBBS FCPS
2. SAMINA RAFIQUE MEMON OBJECTIVE: This study was undertaken to evaluate our institution’s experience with
MBBS (FCPS) Laparoscopic cholecystectomy as a safe and effective treatment for acute and chronic
3. AFTAB AHMED SOOMRO calculus cholecystitis in terms of post operative pain, operative time, rate of conversion
MBBS M.Phil and complications.
4. SYED QARIB ABBAS SHAH STUDY DESIGN: A prospective observational study.
MBBS, MCPS MS PLACE AND DURATION OF STUDY: This study was conducted at Ghulam Muhammad
Mehar Medical College and Hira Medical Centre Sukkur, during a period of last four
1. Asst: Professor years, from Jan 2006 to Dec 2009.
Department of Surgery PATIENTS AND METHODS: It is a prospective study, including 1000 patients undergoing
GHULAM MUHAMMAD MAHAR Laparoscopic surgery for symptomatic cholelithiasis. Patients included in the study were
MEDICAL COLLEGE SUKKUR & divided into two groups. Group I patients presented with chronic cholecystitis (700
SHAHEED MUHATARMA patients), while Group II patients presented with acute gallbladder disease (300 patients).
BENAZIR BHUTTO UNIVERSITY Patients with obstructive jaundice, choledocholithiasis, cholangitis, portal hypertension,
LARKANA. and gallbladder malignancy were excluded from the study.
2. Ex-Registrar & PG Trainee, RESULTS: Among 1000 patients there are 205 (20.5%) males and 795 (79.5%) females.
Dept of Gyne & Obst The mean age was 45 years. The male: female ratio was 1:4. In this study, the laparoscopic
JINNAH POST GRADUATE cholecystectomy was done for chronic calculus cholecystitis in 700 patients, for acute
MEDICAL INSTITUTE KARACHI, calculus cholecystitis in 282 patients and acute acalculus cholecystitis in 18 patients. The
At present registrar in HIRA & median of hospital stay were 2 and 3 days in chronic cholecystitis and acute cholecystitis
GMC Hospital deptt of Surgery respectively (mean were 1.9 versus 3.2 days) [P= 0.0005]. The median of postoperative
Sukkur. stay were 0.83 and 1 day in chronic and acute settings respectively (means 0.82 ± 0.62
3. Asst: Professor versus 1.82 ± 2.9 days) [P= 0.0005]. The open conversion was in 3 (0.428%) patients
Department of Pathology out of 700 with chronic cholecystitis, while in 5 (1.66%) out of 300 patients with acute
GHULAM MUHAMMAD MAHAR cholecystitis. The mean operation time were 39.9 ± 18.8 and 57.8 ± 29.2 minutes in
MEDICAL COLLEGE SUKKUR & chronic and acute cholecystitis respectively (P=0.0005). Minimal complications were
SHAHEED MUHATARMA observed in the chronic group, while major complications like CBD injury and retained
BENAZIR BHUTTO UNIVERSITY CBD stones along with postoperative biliary collections were found in the acute group.
LARKANA. Wound infection occurred in 3.9%. No mortality found in the study.
4. Associate Professor CONCLUSION: Laparoscopic cholecystectomy is superior and beneficial to open
Department of Surgery cholecystectomy in terms of less postoperative pain, decreased hospital stay, early return
GHULAM MUHAMMAD MAHAR to work and minimal complications. It is cost-effective and safe with less postoperative
MEDICAL COLLEGE SUKKUR & morbidity. So, it is a procedure of choice for gallbladder disease.
SHAHEED MUHATARMA
BENAZIR BHUTTO UNIVERSITY KEYWORDS: Laparoscopic cholecystectomy, cholelithiasis, acute and chronic
LARKANA. cholecystitis.
INTRODUCTION:
Correspondence Address: The field of minimally invasive surgery has experienced an explosive growth in the last
DR. MUHAMMAD RAFIQUE two decades.
MEMON Over the last 15 – 20 years since the introduction of video-guided Laparoscopic surgery,
Asst: Professopr majority of the surgical disorders have been successfully performed by minimal access
Department of Surgery approach and the technique has also been standardized. Moreover the outcome of
GHULAM MUHAMMAD MAHAR minimal access surgery in terms of better cure rate and lower morbidity has made
MEDICAL COLLEGE SUKKUR & Laparoscopic surgery the primary treatment replacing the conventional surgery.
SHAHEED MUHATARMA There is little doubt that Laparoscopic surgery will progress to encompass other procedures,
BENAZIR BHUTTO UNIVERSITY and at present there is considerable interest in Laparoscopic repair of inguinal hernias,
LARKANA hiatus hernias and colorectal surgery.1
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Cholelithiasis is a common condition and Table I:
the introduction of laparoscopic
DIFFERENT CONDITIONS FOR GALLBLADDER DISEASE MANAGED
cholecystectomy is an important milestone
LAPAROSCOPICALLY:
in surgical practice that heralds the
development of further minimally invasive Conditions of gallbladder disease No: of patients %
techniques.
The first laparoscopic cholecystectomy was Acute calculus cholecystitis 157 15.7%
performed by Phillip Mouret at Lyon in Acute calculus Cholecystitis
France in 1987. Athough Mouret has never with acute pancreatitis 29 2.9%
published an account of this; the operation
was rapidly adapted by Dubios & co-workers Acute acalculus cholecystitis 18 1.8%
in Paris and the technique spread rapidly Empyema / mucocele 83 8.3%
through France and Germany. Laparoscopic Gangrenous gallbladder 13 1.3%
Cholecystectomy is the “gold standard”
treatment for patients with symptomatic Chronic calculus cholecystitis 658 65.8%
cholelithiasis. Now it has gained rapid Chronic calculus cholecystitis with
acceptance and implementation by general fibrosed gallbladder 42 4.2%
surgeons all over the world.2 Its advantages
are decreased postoperative pain, hospital
stay and morbidity leading to early Table II:
mobilization and early return to diet and RESULTS OF TREATMENT: (AFTER EXCLUDING CONVERTED CASES)
work with cosmetically small scar.
Variable Chronic cholecystitis Acute Cholecystitis
The purpose of this study was to assess
(n=700) (n=300)
the morbidity of laparoscopic
cholecystectomy in our setup and highlight Median hospital stay 2 (0.5 – 10) 3 (1 – 8)
its safety and effectiveness; so that the
patients with gallbladder disease should get Median postoperative stay 0.83 (0.16 – 4) 1 (0.29 – 6)
benefit from this newly developed technique. Operative time (minutes) 38.26 ± 16.6 49.58 ± 18.9
Open conversion 3 5
PATEINTS AND METHODS:
This is a prospective study, including 1000 Mortality 0 0
non-selective patients undergoing
laparoscopic cholecystectomy for acute and
chronic cholecystitis at Ghulam Muhammad evening or night of surgery while regular The median of hospital stay were 2 and 3
Mehar Medical College and Hira Medical diet was resumed on the next morning. A days in chronic cholecystitis and acute
Centre Sukkur during a period of last four majority of patients were usually discharged cholecystitis respectively (mean were 1.9
years (Jan, 2006 to Dec, 2009). 24 hours after surgery. Follow up versus 3.2 days) [P= 0.0005]. The median
All the patients with chronic calculus examination was performed on seventh of postoperative stay were 0.83 and 1 day
cholecystitis who attended the surgical out- postoperative day. in chronic and acute settings respectively
patient department of our institution were All clinical data, investigations, operative (means 0.82 ± 0.62 versus 1.82 ± 2.9 days)
registered and included in the study. They findings, operative time, total hospital stay, [P= 0.0005]. There was statistical significant
were admitted on the day of surgery or a open conversion rate and intra-operative as difference in hospital stay and postoperative
day before surgery. The patients with acute well as post-operative complications were stay between the two groups. 520 (74.28%)
cholecystitis were admitted as an emergency recorded. The data was compiled and results patients out of 700 in chronic cholecystitis
with severe pain in right upper abdomen. drawn and compared with national and and 152 (50.66%) patients out of 300 in
They were managed initially conservatively international literature. Statistical analysis acute cholecystitis were discharged in less
and early laparoscopic cholecystectomy was was carried out using SPSS version 10. than 10 hours after surgery. The open
done within 48-72 hours of their admission conversion was carried out in 3 (0.428%)
or on the next available operation list. RESULTS: patients out of 700 with chronic cholecystitis,
Routine investigations along with ultrasound Among 1000 patients there are 205 (20.5%) while in 5 (1.66%) out of 300 patients
abdomen were carried out. Nature of the males and 795 (79.5%) females. The age of with acute cholecystitis. The causes of open
procedure was explained and consent for patients ranged from 20 – 70 years. The conversion were Mirizzi Syndrome (2
open conversion was also taken. All patients mean age was 45 years. The male: female patients), fibrosed gallbladder with
were given single dose of prophylactic ratio was 1:4. In this study, the laparoscopic cholecystoduodenal fistula (1 patient) in
antibiotics at the time of induction of cholecystectomy was done for chronic chronic group, while in acute group it
anaesthesia, followed by more doses calculus cholecystitis in 700 patients, for included thick adhesions and difficult
postoperatively if required in infected cases. acute calculus cholecystitis in 282 patients dissection (4 patients), and CBD injury (1
The operations were performed using and acute acalculus cholecystitis in 18 patient). The mean operation time were
standard four port technique. Subhepatic patients. Results were analysed in the study 39.9 ± 18.8 and 57.8 ± 29.2 minutes in
drains were placed for most patients with by dividing the patients into two groups. chronic and acute cholecystitis respectively
acute cholecystitis and were used for chronic Group I included patients with chronic (P=0.0005)
cholecystitis whenever considered necessary. cholecystitis, and Group II included patients Minimal complications were observed in
Patients were allowed orally liquids in the with acute cholecystitis. the chronic group, while major complications
291
like CBD injury and retained CBD stones Table III:
along with postoperative biliary collections (a) Intraoperative complications
were found in the acute group. The
Variable Chronic Acute Reasons / management
intraoperative and postoperative
group group
complications of both chronic and acute
group are summarized in Table III. One CBD injury 0 1 Open conversion and T-tube.
patient with CBD injury in acute group Avulsion of cystic duct 2 12 Managed by suturing/ ligation/
was treated by open conversion and T- clipping
tube placement, while two patients who
had missed stones were referred to tertiary Avulsion of cystic artery 3 16 Managed by clipping /
hospital for ERCP. Patients with diathermy
postoperative biliary collections were treated Bleeding from liver bed 8 35 Managed by diathermy or
by percutaneous drainage or medical therapy Argon beam spray.
and open drainage was done for one patient
who developed generalized peritonitis. No Difficult dissection at 32 75 Done by blunt
mortality was found in the study. Thus callot’s triangle and sharp dissection with no
open conversion rate, operative time, complications
postoperative stay, total hospitalization and Spillage of bile and stones 38 85 Managed by picking up
complications were statistically lower in during procedure stones and irrigation/ suction.
chronic group as compared to acute group. No late complications noted.
Gut / solid visceral injury 0 0
DISCUSSION:
In today’s modern world of surgery, (b) Postoperative complications
laparoscopy has major role in many general
Post-operative biliary 2 6 4 cases U/S guided
surgical procedures. Laparoscopic surgery
collection drainage.
is superior and beneficial to open surgery.
3 cases managed
Open surgery may result in increased post-
conservatively. Open drainage
operative pain, delayed mobility, prolonged
in 1 case.
hospital stay, adhesion formation and
incisional hernia.1 On the contrary, after Infra umbilical port 12 27 Application of pyodine
Laparoscopic surgery patient returns to home infection dressing.
and work early. The benefit of minimally Port site serous discharge 23 56 Application of pyodine.
invasive surgery has been well demonstrated
in the treatment of biliary colic, turning Retained CBD stones 0 2 ERCP retrieval of stones.
Laparoscopic cholecystectomy in most Post-op abdominal pain 21 59 Managed by analgesics.
instances in to a truly outpatient procedure.2
In this study, Laparoscopic cholecystectomy Post-op jaundice 1 2
was done in 1000 patients successfully
with minimal complications. The cases of
gallstones with acute and chronic conversion does not guarantee the avoidance only limited in pregnant patients, it could
cholecystitis, acute pancreatitis, mucocele, of inadvertent biliary or vascular injury.1 be safe and efficient.
empyema and gangrenous gall bladder were A meta-analysis of four clinical trials The open conversion rate in this study is
performed laparoscopically with success. involving 504 patients has suggested that 0.428% in the chronic group, while it is
More recently, there has been a move early laparoscopic cholecystectomy is more 1.66% in the acute group. In one of the
towards performing Laparoscopic cost-effective because it is associated with local series it was found 12.73% in acute
cholecystectomy in the acute setting to a reduced length of hospital stay and a cholecystitis, in others 2%, 6% and 14%.8,9
shorten both operative time as well as length lower risk of readmission with recurrent Wang et al reported the overall conversion
of hospitalisation. The current literature acute Cholecystitis.4 Early laparoscopic rate 3.6% for laparoscopic cholecystectomy
suggests early Laparoscopic cholecystectomy during acute cholecystitis in acute cholecystitis 10. Arnalson et al.
cholecystectomy (within 72 hours of onset seems safe and cost-effective by shortening reported the conversion rate of 12.2% for
of symptoms) for acute cholecystitis. Early the total hospital stay.4,5 acute Cholecystitis.11
Laparoscopic cholecystectomy is Laparoscopy was first used for evaluation A dedicated team within hospital specializing
recommended within 72 hours of onset of of acute abdominal pain in pregnancy in in the management of acute gallbladder
symptoms to decrease open conversion 1980 by gynaecologists. The most commonly disease can lead to reduction in the conversion
rates.3 In this sub-group of patients in which reported laparoscopic procedure done during rate in the emergency setting as shown in
Laparoscopic cholecystectomy was done pregnancy is laparoscopic cholecystectomy.6 a study from Portsmouth. 12,13 The
successfully within 48 – 72 hours of onset In this study, laparoscopic cholecystectomy conversion rate during an emergency
of symptoms, only four cases were converted was done in 8 (2.66%) pregnant patients in readmission was significantly higher than
into open because of thick adhesions of first and second trimester with acute calculus the rate at first admission because of
omentum all around the gallbladder and Cholecystitis successfully without technical difficulty in dissection in late
difficulty in adhesiolysis. The dissection complications. Laparoscopy is feasible in laparoscopic surgery. 14,15,16
that is difficult laparoscopically is often an emergency setting, even for pregnant The mean operation time between the two
equally difficult at open operation and patients.7 Though our initial experience is groups was different significantly. In the
292
chronic group it is 39.9±18.8 minutes, while injuries. The literature shows 0.2% to 2% related complications and their best treatment
in the acute group it is 57.8±29.2 minutes in different series.21 In the present study and the proper skill and training of surgeon
(P = 0.0005), which is comparable to the postoperative biliary collection is found about laparoscopy are the key points for
mentioned studies. Chau et al. reported the in only 8 (0.8%) cases. a safe and successful Laparoscopic surgery.
mean operation time in the patients with Intraoperative non-biliary injuries (duodenal
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